Title documentation of problem based assessment of the neurolo

1. Title:
Documentation of problem based assessment of the neurological
system.
Purpose of Assignment:
Learning the required components of documenting a problem
based subjective and objective assessment of neurological
system. Identify abnormal findings.
Course Competency:
Apply assessment techniques for the neurological and
respiratory systems.
Instructions:
Content: Use of three sections:
· Subjective
· Objective
· Actual or potential risk factors for the client based on the
assessment findings with description or reason for selection of
them.
Format:
· Standard American English (correct grammar, punctuation,
etc.)
Resources:
Chapter 5: SOAP Notes: The subjective and objective portion
only
Sullivan, D. D. (2012). Guide to clinical documentation. [E-
Book]. Retrieved from
http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.
com/login.aspx?direct=true&db=nlebk&AN=495456&site=eds-

2. live&ebv=EB&ppid=pp_91
Smith, L. S. (2001, September). Documentation do’s and don’ts.
Nursing, 31(9), 30. Retrieved from
http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.
com/login.aspx?direct=true&db=rzh&AN=107055742&site=eds-
live
Documentation Grading Rubric- 10 possible points
Levels of Achievement
Criteria
Emerging
Competence
Proficiency
Mastery
Subjective
(4 Pts)
Missing components such as biographic data, medications, or
allergies. Symptoms analysis is incomplete. May contain
objective data.
Basic biographic data provided. Medications and allergies
included. Symptoms analysis incomplete. Lacking detail. No
objective data.
Basic biographic data provided. Included list of medications and
allergies. Symptoms analysis: PQRSTU completed. Lacking
detail. No objective data. Information is solely what “client”
provided.
Basic biographic data provided. Included list of medications and
allergies. Symptoms analysis: PQRSTU completed. Detailed. No
objective data. Information is solely what “client” provided.
Points: 1
Points: 2
Points: 3
Points:4

3. Objective
(4 Pts)
Missing components of assessment for particular system. May
contain subjective data. May have signs of bias or explanation
of findings. May have included words such as “normal”,
“appropriate”,
“okay”, and “good”.
Includes all components of assessment for particular system.
Lacks detail. Uses words such as “normal”, “appropriate”, or
“good”. Contains all objective information. May have signs of
bias or explanation of findings.
Includes all components of assessment for particular system.
Avoided use of words such as “normal”, “appropriate”, or
“good”. No bias or explanation for findings evident Contains
all objective information
Includes all components of assessment for particular system.
Detailed information provided. Avoided use of words such as
“normal”, “appropriate”, or “good”. No bias or explanation for
findings evident. All objective information
Points: 1
Points: 2
Points: 3
Points: 4
Actual or Potential Risk Factors
(2 pts)
Lists one to two actual or potential risk factors for the client
based on the assessment findings with no description or reason
for selection of them. Failure to provide any potential or actual
risk factors will result in zero points for this criterion.
Brief description of one or two actual or potential risk factors
for the client based on assessment findings with description or
reason for selection of them.
Limited description of two actual or potential risk factors for

4. the client based on the assessment findings with description or
reason for selection of them.
Comprehensive, detailed description of two actual or potential
risk factors for the client based on the assessment findings with
description or reason for selection of them.
Points: 0.5
Points: 1
Points: 1.5
Points: 2